10 articles General Advice

EPIC – ETSU Discharge Summary Template

ETSU Discharge Summary Template Patient Name: MRN: Admission Date: Discharge Date: Attending on Discharge: Primary Care Physician: Consulations: include name & specialty Primary Discharge Diagnosis: Most pertinent dx for admission Secondary Diagnoses: Ancillary dx in addition to primary Must include all diagnoses treated during hospital course Don’t forget chronic illnesses addressed during admission Procedures: Include…

EPIC – ETSU Progress Note

ETSU Progress Note Overnight events and interval history: Medication Data: Antibiotics including #days and stop date if known IVF/Drips Scheduled meds PRN meds Physical Exam: Vitals: General: HEENT: Cardio: Resp: GI: Ext: Derm: Neuro: Psych: Diagnostics: Labs Micro Imaging EKG: Assessment: List of active diagnoses addressed during today’s visit Optional to include chronic/resolved diagnoses IF…

EPIC – ETSU H&P

ETSU H&P Patient Name: MRN: Date of Admission: Date therapy started Attending Physician: PCP: Chief Complaint: Primary issue that brought patient to the hospital HPI: (history of present illness) Must include 4 out of 8 medicare elements: location, quality, severity, duration, timing, context, modifying factors, associated signs & symptoms Don’t forget pertinent positives and negatives…

Writing physician orders by hand (EHR does not work)

If writing out Physician Orders by hand: Assign to __________ status (observation/inpatient) Attending: Diagnosis: (may be symptoms if Dx is unknown) Vitals: Check q6hrs Allergies: (note reaction to each) Nursing: (special instructions, ex: “oxygen per NC 2L”) Diet: clear liquids and advance as tolerated, NPO, heart healthy Is/Os: q shift Medications: (list out home meds…

Death note

Death: Pronouncing a patient’s death: You may get paged to go to a patient’s room to pronounce their death. Brief PE should include: “Heart and lung sounds are absent. No spontaneous cardiac or respiratory activity. Patient is not responding/nonreactive to verbal or painful stimuli (rub sternum with knuckles). Reflexes absent (ex: corneal blink reflex absent).…